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The Future of PEPFAR Sustainable Results with Accountability, Transparency, and Impact

The Future of PEPFAR Sustainable Results with Accountability, Transparency, and Impact. Ambassador Deborah Birx Global AIDS Coordinator Office of the U.S. Global AIDS Coordinator Department of State 18 June, 2014 HPTN Meeting. History of the Epidemic.

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The Future of PEPFAR Sustainable Results with Accountability, Transparency, and Impact

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  1. The Future of PEPFARSustainable Results with Accountability, Transparency, and Impact Ambassador Deborah Birx Global AIDS Coordinator Office of the U.S. Global AIDS Coordinator Department of State 18 June, 2014 HPTN Meeting

  2. History of the Epidemic Celebrating success and a call to action 1

  3. Maintaining Focus & Momentum is CriticalNumber of New HIV Infections Halved since Peak of Epidemic Trends in New HIV Infections, 1990-2012

  4. Dramatic Impact of PEPFAR on Life ExpectancyIn Countries Significantly Impacted by HIV/AIDS HIV/AIDS Epidemic Source: World Bank, 2014

  5. Budget Realities Necessitate Focus on Core Interventions Reviewing our fiscal environment 2

  6. PEPFAR Bilateral Budget vs. Results(FY 2008 - FY 2015 Request) *FY 2014 includes targets submitted with COP13, to be updated upon completion of COP14 submissions. **FY 2015 targets to be submitted with COP14

  7. Budgetary Realities Require Focus on Critical Activities (Core) Focusing on Highest Impact Interventions • Combination Prevention (PMTCT, ART, Condoms, VMMC) • Prevention (effective/targeted) • OVC – holistic services for families • Neglected & Hard to Reach Populations • Pediatrics • Adolescent girls • Key populations – MSM & TG, FSW, PWID • Health Systems, especially human resources for health, supply chain, lab, and strategic information that will specifically required to support above activities

  8. 3 Country Example of Focus on Core Interventions Meeting Care & Treatment Directive Naturally and Achieving Impressive Program Scale-Up

  9. PROGRAM FOCUS : Prioritizing Activities: Core, Near Core, Non Core Slide from PEPFAR Ethiopia

  10. Geographic Focus: EthiopiaUnequal Burden Requires Review and Re-focusing of Response (Hot Spots) • Challenge of matching program & disease burden • 80% positive clients in 22% of facilities • 400 PMTCT sites with no HIV+ women Slide from PEPFAR Ethiopia

  11. Source: UNAIDS Report on the Global AIDS Epidemic – 2013. Accessible at: http://www.unaids.org/en/dataanalysis/epidemiology/.

  12. Uganda: Focusing on Core with Flat BudgetTreatment Results Uganda Program Review

  13. Uganda: Focusing on Core with Flat BudgetPMTCT Testing and ARV Results Including B+ Scale-Up Uganda Program Review

  14. Uganda: Focusing on Core with Flat BudgetVMMC Scale-Up Uganda Program Review

  15. 4 Implementing for Epidemic Impact Program Priorities for Key Interventions

  16. Focusing Our Programs to Control the Epidemic & Achieve a Sustainable Response • Demonstrate Effective control of the HIV epidemic • Using data to inform programmatic decisions • Going where the epidemic is: populations with high incidence and risk of infection and geographic focus based on prevalence & disease burden • Rapid scale-up of combination prevention • Improve coverage for neglected populations: • Key populations • TB/HIV co-infected • Pediatrics • Young women and girls

  17. Core Interventions & Infections Averted Uganda Zambia Kenya

  18. Close Gaps in ART Coverage for TB/HIV Patients Reaching 100% ART coverage for all TB/HIV patients must be a priority TB is leading cause of death among PLHIV 320,000 PLHIV died of TB in 2012 alone Current ART coverage* among eligible PLHIV *ART Coverage at ART eligibility of CD4<350

  19. Treatment Priorities • Rapidly and strategically scale-up ART, for the greatest impact in achieving epidemic control • Saturate the high prevalence provinces (states) • Support adoption of 2013 WHO guidelines for expanded ART eligibility • Maintain prioritization for the sickest patients • Improve adherence and retention in care with goal of achieving virologic suppression • Ensure community support

  20. Acceleration Needed for EMTCT by 2015 Pre-Global Plan Global Plan Progress 6.5% annual decline 12.7% annual decline Source: Preliminary UNAIDS 2013 Estimates

  21. PMTCT Priorities • Accelerate: strategic scale-up of PMTCT services • Prioritize high-burden areas for saturation • Focus on quality • Ensure 100% access to PITC in PMTCT sites • Rapid testing quality • Improving ART initiation rate among identified positive clients • Improving adherence and retention rates • Support adoption of WHO guidelines – Options B/B+ • Rapidly expand access to and uptake of EID services • Improve post natal follow-up of mother-baby pair

  22. Disparity in ART Coverage Rates for Pediatrics 8 large PEPFAR countries have pediatric coverage <30%

  23. Pediatrics PrioritiesPersistent disparity between adult and pediatric coverage is unacceptable Within 2 years, double number of children on treatment with PEPFAR support in at least 5 countries • Improve pediatric case-finding & immediate linkage to care & ART • Target: 50% increase in PEPFAR-supported EID in two years • Targeted PITC for children in high yield clinical settings • Ensure OVC know status and are linked with care & ART • Engage peer mothers or expert clients to track LTFU • Link families of pediatric patients with OVC services • Train and mentor clinical providers on peds & support task sharing and decentralization • Support pooled procurement with GFATM for peds ARVs & advocate for better formulations • Tailor services for Adolescents

  24. Laboratory Priorities • Quality assurance for rapid HIV testing • Ensure accurate results are provided to clients • Rapid testing quality improvement initiative (RTQII) • Develop country-specific strategies for scale-up of viral load testing and development of viral load networks • VL Implementation Guide to be launched at IAS (collaboration between PEPFAR, WHO, GF, ASLM).

  25. Viral Load in Resource-Limited Settings Viral load is the gold standard for ART monitoring • 2013 WHO Guidelines • VL testing at 6 months and then annually for patients on ART to monitor adherence and detect treatment failure • WHO historically focused on clinical & immunologic monitoring for patients on ART  poor predictive value for virologic failure • Delayed detection of failure leads to accumulation of HIV drug resistance • New developments have made VL more feasible • Prices fallen to as low as $10.50/test* in some countries (compared to $40-85/test) • Use of dried blood spots (DBS) mitigates many specimen collection and transport issues *$10.50/test reflects reagents only; total cost of test is ~$20/test with overhead, transport, other equipment costs.

  26. Prevention PrioritiesFocus, Measurement, Quality Focus • High impact interventions • VMMC, Condoms, HTC and demand creation for clinical services • High need populations • KPs, fishing communities, adolescent girls • High impact locations Measurement • Define population sizes • Set aggressive targets to reach meaningful coverage • Quantify the impact in the short and long term Quality • Define a standard package of evidence-based services • Track partner performance • Be accountable for improvement • Support policy-level interventions for maximum impact

  27. Moderate Increase in Condom UseCondoms are a core combination prevention intervention

  28. VMMC Priorities • Continue scale-up with focus on efficiencies to decrease unit cost while maintaining quality • Introduce non-surgical devices to facilitate task sharing and appeal to clients • Innovations in demand creation including social marketing • Continuing focus on safety and infection control • Prioritizing outreach to age groups most at risk of acquiring HIV Number of Voluntary Medical Male Circumcisions Supported by PEPFAR Source: PEPFAR program data, 2013

  29. Broad Societal Benefits of ART For every 1000 patient-years of treatment: • 226 patient deaths averted • 432 children not orphaned • 60 sexual transmissions of HIV averted • 39 vertical (mother-to-child) infections averted • 9 TB cases averted among HIV patients • 2,419 life-years gained Source: CDC estimates from the PEPFAR ART Cost Model (PACM) for the Office of the U.S. Global AIDS Coordinator, based on PEPFAR FY2013 APR results

  30. Number of Children Orphaned by AIDSNumber of AIDS Orphans in Sub Saharan Africa Continues to Grow The number of children who have lost their parents due to HIV has increased from 14.6 million in 2005 to 17.8 million in 2013. Source: UNAIDS & UNICEF, 2013

  31. PEPFAR OVC Mission: To mitigate the social, emotional and economic impacts of HIV/AIDS on children and to reduce their risk and vulnerability while increasing their resilience. OVC Priorities Mission & OVC Strategic Principles OVC Strategic Principles • Strengthen families as primary caregivers of children; • Support the capacity of communities to create protective and caring environments; • Build the capacity of social service systems to protect the most vulnerable; and • Allocate resources for children according to need in the context of HIV/AIDS by integration with the broader PEPFAR platform and response

  32. South Africa: OVC 2014 Q1 & Q2 data Age 0<2 Age 2 to <6 Age 6 to <12 Age 12 to <14 Age 14 to <18

  33. 5 Disparities in Access to Lifesaving Services Getting the right services to the right populations in the right places

  34. Disparately High HIV Prevalence among Young Women Compared to Young Men Estimated HIV Prevalence Among Young Women & Men (15-24 years) in Eastern and Southern Africa, 2011 Source: UNAIDS 2013

  35. HIV Incidence among Young WomenMore than 1/3 New HIV Infections Globally Occur among Young Women in Africa Over 5,000 new HIV infections every week among young women in these 14 countries alone

  36. Violence Against Children Surveys (VACS) • Reducing Gender Based Violence is a Critical Priority • *Among females reporting sexual debut before age 18 • **Data for Tanzania and Swaziland reported by 13-24 year olds Sources: UNICEF Swaziland and CDC. Findings from a National Survey on Violence Against Children in Swaziland. CDC, Atlanta. 2007 UNICEF Tanzania, CDC, and Muhimbili University of Health and Allied Sciences. Violence against Children in Tanzania: Findings from a National Survey 2009. Dar es Salaam, Tanzania. 2011 UNICEF Kenya, CDC, and Kenya National Bureau of Statistics. Violence against Children in Kenya: Findings from a 2010 National Survey. Nairobi, Kenya. 2012 Zimbabwe National Statistics Agency. National Baseline Survey on Life Experiences of Adolescents in Zimbabwe 2011. Preliminary Report. 2012 CDC, Interuniversity Institute for Research and Development, Comité de Coordination. Violence against Children in Haiti: Findings from a National Survey, 2012. Port-au-Prince, Haiti: Centers for Disease Control and Prevention, 2013

  37. Violence Against Children Surveys (VACS) Association between childhood sexual violence and selected health conditions, reported by females 13-24 years old in Swaziland • *Adjusted for age, community setting, SES, and orphan status Source: UNICEF Swaziland and CDC. Findings from a National Survey on Violence Against Children in Swaziland. CDC, Atlanta. 2007

  38. Elevated Incidence Among Key Populations in Concentrated Epidemics New HIV Infections by Population in Regions with Majority Concentrated Epidemics Source: UNAIDS, 2013

  39. Discriminatory Cultural & Legal Environments Substantial Impact on MSM, TG, PWID, and Other Vulnerable Populations Cultural and political environments contributing to stigma and discrimination significantly impact access to life-saving services for many populations. Characteristic Malawi Namibia Botswana MSM afraid to seek health services 18% 18% 21% MSM afraid to walk in community 16% 17% 29% MSM blackmailed because of sexuality 18% 21% 27% MSM beat up by govt/police official 8.% 22% 2% Source: Beyrer et al, 2010

  40. 6 The Power of PEPFAR Focusing our collective energy to end AIDS

  41. Defining Success for PEPFAR Controlling the Epidemic • All long term strategy countries reach 80% coverage for all core elements of combination prevention • Dramatically improve pediatric treatment coverage & linkage with OVC services • Ensure prevention and key pops programs are focused and evidence-based • VL strategically rolled-out and ART patients with full viral suppression • Adherence to ART at 80-85% with full viral suppression Sustainability & Partnership • Full transparency, data sharing, and renewed engagement with civil society • Collaborative planning, monitoring, and TA with GFATM/PEPFAR • Coordination with multilateral, faith-based, and private sector partners Accountability and monitoring • 100% site monitoring achieved and all countries reporting real-time data • Interagency Collaborative successfully operating – use of program data for budget formulation and TA prioritization

  42. Celebrating Progress • 6.7 million women, men and children on life-saving antiretroviral treatment • 780,000 HIV+ pregnant women received ARVs to prevent mother-to-child transmission • 2.2 million men received VMMC services • 17 million people received care and support • 5 million orphans and vulnerable children supported • 57.7 million people received HIV testing and counseling services • 21 million people in priority and key populations reached with risk behavior prevention interventions

  43. Focus on those we serve : This WEEK Over 4,000 babies were infected Over 5,000 young women were infected Over 24,000 people living with HIV died on this continent

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